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RK531  W15  An  atlas  ot  dental  e 


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AN   ATLAS   OF 

DENTAL    EXTEACTIONS 


WITH 


NOTES  ON  THE  CAUSES  AND  RELIEF 
OF  DENTAL  PAIN 


C.  EDWARD  WALLIS,  M.R.C.S.,  L.R.C.P.,  L.D.S. 

ASSISTANT   DENTAL    SURGEON    KINO'S   COLLEGE    HOSPITAL  ; 

ASSISTANT    MEDICAL    OFFICER    (EDUCATION)    LONDON    COUNTY    COUNCIL; 

LATE    DENTAL    SURGEON    VICTORIA    HOSPITAL    FOR    CHILDREN, 

CHELSEA,    ETC. 


PHILADELPHIA 

P.    BLAKTSTON'S    SOX    &    CO. 

1012,    WALNUT    STREET 

1000 


By  the  same  Author. 


THE    CAEE    OF    THE    TEETH 

IN 

PUBLIC    ELEMENTARY    SCHOOLS 

With  Special  Reference  to  what  is  being  done  in  Germany. 
With  6  Illustrations  and  Chart. 


PRINTED    IN    great    BRITAIN. 


PREFACE. 

This  atlas  and  notes  have  been  designed  for  tlie  use 
of  medical  students  and  practitioners  with  the  object  of 
assisting  them  to  perform  such  emergency  dental  opera- 
tions as  may  be  expected  to  occur  in  a  country  practice 
or  on  board  ship  where  the  services  of  a  dental  surgeon 
cannot  be  obtained. 

A  minimum  number  of  dental  appliances  has  been 
recommended  and  various  means  of  improvising  a  dental 
chair  have  been  shown. 

I  have  to  express  my  great  indebtedness  to  Professor 
Underwood,  Dr.  Harold  Austen,  Mr.  Norman  Bennett, 
and  Mr.  Gr.  K.  Aubrey  for  many  valuable  suggestions, 
and  also  to  Messrs.  Allen  &  Hanburys  for  the  loan  of 
the  blocks. 

C.   E.  WALLIS. 

.38,  Queen  Anne  Street  ; 
June,  1909. 


LJST    OF    PLATES. 

1.  EXTEACTIOX    OF    UpPEK    InCISOKS    AND    C'aNINES. 

2.  Extraction  of  Lower  Incisors,  Lower  Canines,  and  Incisor 

AND  Canine  Eoots. 

3.  Extraction  of  Eight  and  Left  Upper  Bicuspids. 

4.  Extraction   of  Eight  Lower  Bicuspids  and   Lower  Eoots 

ON  THE  Eight  Side  of  the  Mouth. 

5.  Extraction    of    Left   Lower    Incisors,  Bicuspids,  and  all 

Eoots  on  Left  Side  of  Mouth. 

6.  Extraction  of  Eight  Upper  Molars. 

7.  Extraction  of  Left  Upper  Molars. 

8.  Extraction  of  Eight  Lower  Molars. 

9.  Extraction  of  Left  Lower  Molars. 

lU.  Extraction  of  Upper  and  Lower  Eoots  and  Lower  Wisdom 
Teeth. 

IL  The  Use  of  the  Elevator  for  Extracting  Lower  Stumps 
and  Lower  Wisdom  Teeth. 


THE    CAUSES     AND     RELIEF    OF    DENTAL 

PAIN. 

In  studying  the  causes  of  toothache  one  must  bear  in 
mind  the  various  structures  of  which  a  tooth  is  com- 
posed, and  the  surrounding  tissues  with  which  it  is  in 
close  relation.  A  tooth  may  l^e  regarded  as  a  hard, 
unyielding  box,  enclosing  a  highly  sensitive  and  vascular 
pulp  or  "  nerve  "  as  it  is  commonly  called. 

The  portion  of  tooth  which  is  implanted  in  the  jaw  is 
more  or  less  conical  in  shape  and  closely  surrounded  by 
its  bony  socket,  which  is  therefore  a  hollow  cone. 

Between  the  root  and  the  socket  is  a  fibrous  mem- 
brane known  as  the  "  dental  periosteum,"  in  which  a 
capillary  network  ramifies  for  the  nutrition  of  the  socket 
and  the  external  surface  of  the  root ;  and  through  this 
membrane  pass  the  blood-vessels  that  enter  the  pulp. 

Irritation  applied  to  any  vascular  tissue  produces 
hyjjersemia,  which  may  l)e  l)ut  transitory  or  pass  into  the 
condition  of  mflcnmnation  if  the  irritant  be  not  speedily 
removed. 

It  is  important,  therefore,  to  distinguish  two  different 
Hources  of  the  pain  of  tootbache  according  as  the  pulp  or 
the  dental  periosteum  is  the  part  primarily  affected,  for 
on  the  correctness  of  diagnosis  will  depend  the  chance 
of  successful  treatment. 

Inflanimofiov    of  the  j)?//^>.— The   hyperaemia    of   the 


2  CAUSES  AND  EELIEF  OF  DENTAL  PAIN. 

pulp  occurring  in  this  condition  leads  to  swelling  that 
causes  a  darting,  shooting,  or  throbbing  pain  in  the 
tooth,  owing  to  the  resistance  offered  by  the  unjdelding 
wall  of  the  pulp  cavity  to  the  expansion  of  the  pulp 
tissue. 

Heat  or  a  lowered  position  of  the  head  intensifies  the 
throbbing,  since  either  will  still  further  increase  the 
congestion. 

As  the  dental  periosteum  is  not  involved,  pain  is  not 
usually  felt  on  the  tooth  being  pressed  or  bitten  into  its 
socket. 

Inffammation  of  the  dental  periosteum. — This  membrane, 
on  becoming  inflamed,  is  thickened,  and  therefore  raises 
the  tooth  in  its  socket ;  hence  it  appears  lengthened  and 
is  bitten  upon  before  its  neighbours  when  the  jaws  are 
closed,  pain  being  produced  from  the  periosteum  being 
squeezed  between  the  two  unyielding  surfaces  of  tooth 
and  socket. 

The  pain  is  of  a  dull,  heavy,  not  throbbing  character, 
not  worse  at  night,  and  often  relieved  by  heat  and  gene- 
rally in  early  stages  by  pressure. 

The  tooth  is  tender  to  the  slightest  touch,  and  the  gum 
surrounding  it  is  swollen  and  feels  velvety  to  the  finger. 

Irritation  of  the  dental  pulp. — If  the  irritation  be  long 
continued  and  slight,  an  increased  formation  of  dentine 
may  take  place  from  stimulation  of  the  odontoblasts. 

Irritation  of  the  dental  pulp  may  arise  from : 

(1)  Caries  with  or  without  the  presence  of  cavities. 

(2)  Heat  and  cold ;  contact  of  sweet,  sour,  or  acid 
substances. 

(3)  Conduction  of  heat  and  cold  through  a  metal  filling. 

(4)  Exposure  of  dentine  from  any  cause  producing 
loss  of  the  enamel,  such  as  friction  from  bands  or  dental 
plates,  wearing  down  of  teeth  from  excessive  use. 


CAUSES  AXD  RELIEF  OF  DENTAL  PAIN.  3 

Sjimpturiis. — The  symptoms  depend  upon  the  amount 
of  hypera3mia;  thus  shght  discomfort  may  follow  on 
taking  hot  or  cold  fluids,  the  contact  of  cold  air,  etc. 

The  pain,  however,  is  usually  of  a  shooting  or  darting 
character  and  occurring  at  irregular  intervals,  sometimes 
brought  on  by  heat  or  cold,  especially  cold,  or  by  the 
contact  of  sweet,  salt,  or  sour  substances. 

The  tooth  may  also  be  tender  to  the  slightest  touch 
owing  to  an  extension  of  the  hypergemia  to  the  dental 
periosteum. 

Treatment. — When  the  pain  is  due  to  the  presence  of 
a  cavity  in  the  tooth  it  must  be  thoroughly  syringed  with 
warm  water,  and  into  the  cavity  must  be  inserted  a 
small  pellet  of  cotton-w^ool  that  has  been  dipped  in  one 
of  the  following  local  anaesthetic  substances  (it  is  essen- 
tial to  squeeze  the  excess  from  the  pellet,  as  it  is  undesir- 
able for  the  medicament  to  overflow  into  the  mouth) : 

Oil  of  cloves. 

Eugenol. 

Creosote. 

Oil  of  cinnamon. 

Strong  liquefied  carbolic  acid. 

Warm  saturated  solution  of  carbonate  of  soda. 

Oil  of  peppermint. 

Cocaine  crystals,  especially  the  crystals  dissolved  in 
glycerine  1  in  o. 

Carljolised  resin  is  a  most  convenient  preparation  for 
the  purpose,  as  in  addition  to  relieving  pain  it  serves  as 
a  temporary  stopping  for  two  or  three  days  until  a 
dentist  can  be  seen. 


Formula/or  Carbolised  Ream. 

Resiu 

4  parts 

Carlwlic  acid  crystals         .         .         .         . 

4  parts 

Chloroform        .         .                   .                   . 

8  parts 

4  CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

In  cases  in  which  owing  to  the  loss  of  the  enamel  the 
dentine  has  become  exposed  and  highly  sensitive  to  heat 
and  cold,  relief  can  be  obtained  almost  immediately  by  the 
application  of  solid  nitrate  of  silver  to  the  sensitive  area; 
the  most  convenient  plan  is  to  fuse  a  little  of  the 
powdered  salt  on  the  end  of  a  probe  or  hair-pin  so  as  to 
form  a  bead,  which  can  be  readily  applied  to  any  part  of 
the  mouth. 

When  there  is  no  visible  cavity  it  is  well  to  treat 
the  pain  on  general  constitutional  principles  with  anti- 
neuralgic  remedies,  such  as  chloral  hydrate,  exalgin, 
antipyrin,  gelsemium,  phenacetin,  and  so  forth.  The 
application  of  iodine  and  aconite  paint  to  the  gums  in  the 
vicinity  of  the  painful  tooth  frequently  affords  great  relief 
by  the  counter-irritation  and  anodyne  effect  produced. 

Iodine  and  Aconite  Paint. 

5J:      Liquor  iodi  fortis  ^  , 

T  •  -J.-  >  equal  parts, 

liin.  aconiti  J    ^        ^ 

To  be  applied  to  the  gums  on  a  small  swab  of  cotton- wool  not  more 

than  twice  daily. 

In  severe  and  urgent  cases  it  may  be  necessary  to 
administer  morphine  hypodermically.  In  all  cases, 
however,  in  which  no  cavity  can  be  seen,  the  patient 
should  be  advised  to  consult  a  dentist,  who  may  be  able 
to  find  a  dental  cause  not  discoverable  without  the  use  of 
special  dental  appliances. 

Acute  infiammation  of  the  indp  is  usually  the  result  of 
its  exposure  or  infection  by  the  advance  of  caries ;  it  may, 
however,  be  produced  by  the  fracture  of  a  tooth  due  to  a 
blow,  the  application  of  arsenious  acid  for  destroying  the 
pulp,  or  as  an  extension  of  inflammation  from  the  dental 
periosteum. 

If  a  section  be  made  through  a  tooth  the  pulp  of  which 
is  in  a  state  of  acute  inflammation,  the  pulp  tissue  will 


CAUSES  AND  RELIEF  OF  DENTAL  PAIN.  5 

be  seen  to  be  bright  red,  whereas  a  healthy  dental  pulp 
is  of  a  very  pale  pink  colour. 

Symptoms. — Pain,  usually  of  a  shooting  character, 
brought  on  by  food  pressing  against  the  exposed  surface 
or  by  the  application  of  heat  or  cold,  and  in  its  early 
stages  characteristically  intermittent. 

The  pain  is  icorse  at  night,  when  the  patient  lies  down 
and  becomes  warm  in  bed,  increased  congestion  l)eing 
thus  produced ;  the  pulp  is  squeezed  against  the  hard, 
unyielding  walls  of  the  pulp  cavity. 

The  pain  may  or  may  not  be  referred  by  the  patient 
to  the  tooth  really  affected,  a  lower  tooth  being  fre- 
quently indicated  by  the  patient  as  the  one  in  fault  when 
the  real  source  of  pain  is  an  upper  one. 

Referred  dental  pain,  however,  never  crosses  the 
median  line. 

Examples  of  referred  pain. — Earache  is  frequently  due 
to  a  carious  molar  tooth.  Pain  in  the  bicuspid  or  canine 
region  may  also  be  due  to  a  carious  wisdom  tooth  on  the 
same  side  of  the  mouth. 

Course. — If  the  acute  inflammation  of  the  pulp  be 
allowed  to  run  its  course  untreated,  the  pulp  usually 
becomes  strangulated  at  the  apical  foramen  and  its  death 
results  ;  death  of  the  pulp,  however,  may  not  occur  until 
a  second  or  third  attack. 

Treatment. — The  first  indication  is  the  relief  of  pain, 
and  this  may  be  accomplished  by  the  same  means  as  for 
the  pain  due  to  irritation  of  the  pulp,  namely,  the  insertion 
of  a  pellet  of  cotton-wool  dipped  in  one  of  the  following  : 

Oil  of  cloves,  eugenol,  creosote,  oil  of  cinnamon,  pure 
carVjolic  acid,  oil  of  peppermint,  a  warm  saturated  solu- 
tion of  carbonate  of  soda,  or  crystals  of  cocaine;  carbo- 
lised  resin  ^  is  also  useful  for  this  purpose,  and  has  the 

'  See  "  Formula  for  Carbolised  Resin  "  on  p.  3. 


6  CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

additional  advantage  of  serving  as  a  temporary  stopping 
for  three  or  four  days. 

Treatment. — If  pain  of  a  severe  throbbing  character 
has  lasted  for  some  time  destruction  of  the  dental  pulp 
is  usually  advisable;  this  is  effected  by  the  application 
of  some  preparation  containing  not  more  than  gr.  Ye 
arsenious  acid  to  the  exposed  pulp,  the  preparation 
being  carefully  retained  in  position  by  gutta-percha  or 
wool  soaked  in  sandarac  or  mastic  varnish.  Arsenic 
should  not  as  a  general  rule  be  applied  to  temporary  teeth. 

The  process  of  "  killing  the  pulp  "  should  be  in  most 
cases  a  painless  one ;  in  the  cases  in  which  much  pain 
ensues  the  cause  is  usually  the  application  of  too  tight  a 
dressing,  which  does  not  allow  of  the  expansion  of  the 
pulp  due  to  the  congestion  produced  by  the  arsenic. 
The  application  of  arsenic  for  this  purpose  should  not 
be  undertaken  by  anyone  without  special  training,  as  it 
is  frequently  a  matter  of  considerable  difi&culty,  and  may 
cause  sloughing  of  the  gums  and  necrosis  of  the  alveolus 
if  carelessly  performed. 

Chronic  suppurative  inflammation  of  the  pulp  usually 
arises  from  infection  of  the  dental  pulp  that  has  been 
exposed  by  caries. 

Symptoms. — Pain  coming  on  at  irregular  intervals  of  a 
wandering  neuralgic  character,  which  the  patient  may  not 
refer  to  a  tooth  at  all;  the  presence  of  throbbing  is  not  in- 
frequent, and  may  assist  in  locating  the  source  of  the  pain. 

A  paroxysm  is  often  brought  on  by  the  sudden  applica- 
tion of  heat  or  cold,  sweet  or  salt  substances.  The 
characteristic  symptom  of  suppurative  inflammation  of 
the  pulp  is  the  production  of  great  increase  of  pain  on 
the  application  of  heat. 

The  tooth  is  not  tender  unless  the  periosteum  is  involved 
and  the  gum  is  not  swolleii. 


CAUSES  AND  RELIEF  OF  DENTAL  PAIN.  7 

Treatmenf. — -Tlie  application  of  local  angestlietics  and 
sedatives  on  cotton-wool  as  for  irritation  of  dental  pnlp  ; 
opening  the  pulp  chamber  usually  gives  immediate  relief, 
but  is  a  procedure  that  can  only  be  carried  out  with  special 
dental  instruments.  General  constitutional  treatment 
must  therefore  be  used  to  supplement  local  palliative  ap- 
plications until  skilled  dental  treatment  can  be  obtained. 

Polypus  of  the  pulp. — Sprouting  granulation  of  the 
exposed  surface  of  a  chronically  inflamed  pulp  may  take 
place,  the  granulations  growing  till  the  carious  cavity  is 
completely  filled  by  them,  constituting  what  is  known  as 
pohiptus  of  the  pulp  ;  a  polypus  of  this  kind  is  not  usually 
very  sensitive. 

Treatment. — The  polypus  must  be  cut  away  and  the 
pulp  destroyed  by  arsenious  acid. 

Dental  periostitis  {periodontitis,  p)ericementitis) . — In- 
flammation of  the  fibrous  and  vascular  membrane  which 
lines  the  socket  of  a  tooth  and  covers  and  nourishes  the 
cementum  is  called  variously  "  dental  periostitis,"  "  peri- 
odontitis," and  "  pericementitis." 

It  may  be  general,  involving  the  periosteum  of  all  the 
teeth,  or  local,  being  in  that  case  confined  to  the  socket 
of  one  tooth  only  ;  like  inflammation  elsewhere,  it  may 
be  acute  or  chronic. 

General  inflammation  of  the  dental  periosteum  is 
dependent  on  some  constitutional  condition,  such  as 
rheumatism,  gout,  tuberculosis,  syphilis,  or  may  be  asso- 
ciated with  one  of  the  exanthematous  fevers,  the  inhala- 
tion of  the  fumes  of  phosphorus  as  in  match-makers,  tlie 
administration  of  mercury. 

Localised  dental  periostitis  may  be  acute,  frequently 
running  on  to  alreolar  abscess,  or  chronic,  in  Avhich 
suppuration  either  does  not  occur  at  all  or  is  restricted 
to  the  periosteum  iwar  the  'nLfm/iv  of  the  sorfct. 


8  CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

Acute  localised  deiital  periostitis. — Causes  :  (1)  Inflam- 
mation spreading  from  a  living  inflamed  pulp,  througli 
the  apical  foramen  to  the  periosteum  immediately  sur- 
rounding it. 

(2)  Direct  absorption  by  the  periosteum  of  septic 
material  from  a  putrefying  pulp. 

(3)  Stopping  an  imperfectly  sterilised  tooth  from 
which  septic  material  is  unable  to  escape,  except  through 
the  apical  foramen. 

(4)  Injury  caused  by  a  blow  upon  the  tooth,  injuring 
and  perhaps  leading  to  infection  of  the  periosteum. 

(5)  The  escape  of  arsenic  from  a  dressing  applied  for 
the  destruction  of  a  dental  pulp. 

(6)  Exposure  and  infection  of  the  periosteum  super- 
vening in  the  condition  known  as  pyorrhoea  alveolaris 
(Riggs'  disease). 

Si/mptoms. — In  the  early  stages  the  tooth  or  teeth  may 
be  merely  tender  and  uncomfortable ;  later,  however, 
owing  to  the  swelling  of  the  dental  periosteum  the  affected 
teeth  become  raised,  as  well  as  loose  and  tender  to  the 
slightest  touch. 

The  gums  also  become  involved,  since  the  dental 
periosteum  is  reflected  outwards  at  the  margin  of  the 
alveolus,  and  become  swollen  and  deeply  congested, 
presenting  a  velvety  feeling  when  touched  by  the  finger. 

Sudden  changes  of  temperature  or  weather  will  often 
bring  on  or  accentuate  an  attack  of  dental  periostitis  in 
those  subject  to  this  affection. 

When  dental  periostitis  is  produced  by  mercury  or 
phosphorus,  there  is  tenderness  and  loosening  of  the 
teeth,  extreme  congestion  of  the  gums,  which  become 
spongy  and  readily  bleed,  together  with  great  oral  foetor. 

Ulceration  with  sloughing  of  the  gums  and  necrosis  of 
the  jaw  may  ensue. 


CAUSES  AND  RELIEF  OF  DENTAL  PAIN.  9 

Ptyalism  is  especially  marked  in  mercurial  poisoning. 

General  treatment— Conditutional :  Remove  the  cause 
if  possible,  as  in  the  case  of  mercury  and  phosphorus 
poisoning. 

Treat  general  condition  if  gouty,  rheumatic,  tuber- 
culous, or  syphilitic. 

Local— Ken^ev  the  mouth  as  aseptic  as  possible  by  the 
use  of  mouth  washes,  of  which  sanitas  combined  with 
chlorate  of  potash  lotion  (gr.  x  to  the  ounce)  is  one  of 
the  best. 

In  cases  in  which  one  or  more  teeth  are  involved, 
counter-irritation  applied  by  first  drying  a  large  area  of 
the  gums  near  the  aifected  teeth  and  then  painting  it 
with  iodine  and  aconite  jMiint  gives  great  relief. 

Formula. 

^     Liquor  iodi  fortisl 

Lin.  acouiti  j*  equal  parts. 

This  should  not  be  applied  more  than  twice  or  three 
times  daily,  as  it  tends  to  make  the  mucous  membrane  so 
sore  that  further  applications  become  impossible. 

The  application  of  a  capsicum  plaster,  which  is  a  sort 
of  diminutive  mustard  leaf,  to  the  previously  dried  gum 
also  gives  great  relief ;  it  should  be  held  over  the  root  of 
the  afPected  tooth  with  the  finger  until  it  adheres,  and 
then  allowed  to  remain  until  it  falls  off. 

Chronic  localised  dental  periostiti.s.— This  condition 
must  be  treated  in  the  same  way  as  the  above,  by 
general  constitutional  treatment  and  l^y  the  application 
of  the  iodine  and  aconite  paint  night  and  morning,  or 
if  more  convenient  by  the  application  of  capsicum 
plasters. 

Chronic  suppurative  dental  periostitis— pyorrhwa  alveo- 
laris.— The  pathology  of  this  condition  is  very  obscure  ; 
it  is  apparently  due  to  a  pyogenic  infection. 


10         CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

8y7nptoms. — Those  of  suppuration  of  the  dental  peri- 
osteum, plus  inflammation  of  the  gums  (gingivitis), 
accompanied  by  the  formation  of  deep  pockets,  from 
which  pus  exudes  round  the  necks  of  the  teeth,  leading 
to  destruction  of  dental  periosteum,  absorption  of  the 
alveolus,  and  loosening  of  the  teeth.  . 

Treatment. — The  treatment  of  this  condition  is  exceed- 
ingly unsatisfactory ;  at  the  same  time  efforts  must  be 
made  to  minimise  the  suppuration  by  the  use  of  antiseptic 
mouth-washes,  such  as  chlorate  of  potash  in  combination 
with  sanitas,  permanganate  of  j)otash,  etc. 

Alveolar  abscess. — An  abscess  arising  from  a  tooth  is 
known  as  an  alveolar  abscess  or  "  gum-boil " ;  it  is 
usually  situated  at  the  end  of  the  root  of  a  tooth. 

Causes. — Extension  of  septic  infection  from  the  pulp 
or  periosteum  of  a  tooth. 

Symptoms. — Those  of  dental  periostitis  much  inten- 
sified, e.  g.  the  tooth  is  raised  and  tender ;  the  gums  are 
swollen,  deeply  congested;  pus  frequently  wells  up  at 
side  of  tooth. 

Sulcus  between  cheek  and  tooth  instead  of  being 
hollow  is  filled  up  by  a  globular  or  diffuse  swelling. 

Sometimes  diffuse  cellulitis  of  the  face  occurs,  the 
whole  cheek  becoming  swollen,  tense,  shining,  very 
painful,  and  the  eye  closed  if  the  abscess  is  connected 
with  an  upper  tooth.  The  pus  from  an  upper  tooth  may 
burrow  into  the  antrum  in  the  case  of  upper  bicuspids  (or 
molars),  or  be  directed  towards  the  palate  (upper  lateral 
incisor)  either  between  the  periosteum  and  the  bone, 
when  there  will  be  great  pain,  or  between  the  periosteum 
and  the  mucous  membrane,  when  there  will  be  but  little 
pain,  since  the  tissue  in  that  situation  is  somewhat  lax 
and  therefore  yields  readily. 

When   an  abscess  is  situated  at  the  root  of  a  lower 


CAUSES  AND  RELIEF  OF  DENTAL  PAIN.        11 

molar,  particularly  a  lower  wisdom  tooth,  trismus  may 
occur  from  : 

(1)  Spasm  of  the  masseter,  Avhich  symptom  will  dis- 
appear under  an  anesthetic. 

(2)  Inflammatory  infiltration  of  the  masseter,  in  which 
case  the  administration  of  an  angesthetic  will  simply 
enable  the  operator  to  apply  the  necessary  force  to  open 
the  jaw  with  a  screw  wedge  or  Mason's  gag. 

An  abscess  from  a  lower  wisdom  tooth  sometimes 
points  beneath  the  angle  of  the  jaw,  and  an  abscess 
connected  with  any  lower  tooth  may  burst  either  through 
the  cheek  or  beneath  the  margin  of  the  mandible. 

The  submaxillary  lymphatic  glands  sometimes  be- 
come infected,  in  which  case  they  will  be  swollen  and 
tender. 

The  submaxillary  lymphatic  glands  in  children  are 
sometimes  infected  with  tubercle,  probably  conveyed  to 
the  glands  by  carious  teeth  with  exposed  pulps. 

Treatment  of  alveolar  abscess. — When  an  alveolar 
abscess  has  already  formed,  great  relief  will  usually  be 
obtained  by  incising  the  abscess  in  the  mouth. 

In  cases  in  which  the  abscess  is  very  large  and  is 
threatening  to  burst  outside  the  cheek,  it  is  wise  to 
apply  a  piece  of  gauze  with  flexible  collodion  over  the 
thinned  area  of  skin,  and  thus  to  minimise  the  danger  of  or 
prevent  the  occurrence  of  an  external  opening;  at  the 
same  time  efforts  must  be  made  to  make  the  abscess 
point  in  the  mouth,  and  this  is  best  done  by  the  application 
of  a  roasted  dried  fig  or  a  dried  fig  squeezed  dry  from 
boiling  water  and  held  in  the  mouth  over  the  abscess ; 
it  is  often  necessary  to  apply  a  succession  of  these  fig 
poultices. 

Poppy-head  fomentation,  made  by  Ijoiling  two  ounces 
of   bruised  poppy-lieads  for   ten   minutes  in  a  pint  of 


12         CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

water  and  held  in  the  month,  often  gives  great  relief  and 
may  shorten  the  course  of  the  affection. 

In  severe  cases  of  ah^eolar  abscess  extraction  of  the 
tooth  is  the  only  course  open  to  the  medical  practitioner, 
and  the  sooner  it  is  done  the  better  for  the  patient ;  the 
old  idea  that  it  is  necessary  to  wait  till  the  inflammation 
has  subsided  is  often  disastrous  to  the  patient,  as  it  may 
lead  to  the  formation  of  an  external  opening  in  the  cheek 
and  permanent  scarring  of  the  face. 

An  abscess  arising  from  a  lower  wisdom  tooth  usually 
necessitates  its  extraction,  this  is  often  a  matter  of  great 
difficulty,  and  can  only  be  accomplished  by  using  the 
elevator;  it  sometimes  happens  that  it  is  impossible  to 
reach  the  wisdom  tooth,  in  which  case  it  may  be  necessary 
to  remove  the  second  lower  molar  before  dealing  with 
the  offending  wisdom  tooth. 

Local  ansesthesia  in  the  extraction  of  teeth. — Though 
still  to  some  extent  on  its  trial,  the  hypodermic  injection 
of  certain  anaesthetic  solutions  is  in  a  considerable 
number  of  cases  successful  in  enabling  the  extraction  of 
teeth  to  be  performed  painlessly.  At  the  same  time  it 
is  essential  for  the  operator  to  know  exactly  what  he  is 
injecting  and  the  exact  amount  and  purity  of  the  active 
ingredient  contained  in  his  injection. 

Nothing  can  be  more  dangerous  than  the  injection  of 
the  much  advertised  proprietary  local  anaesthetics,  most 
of  which  contain  an  indefinite  amount  of  cocaine,  and 
which  within  the  writer's  knowledge  have  over  and  over 
again  produced  serious  results. 

Cocaine  is  certainly  to  be  avoided  in  all  these  prepara- 
tions. 

There  are  no  absolutely  reliable  and  satisfactory  pre- 
parations for  the  purpose,  though  novocaine  (which  is  a 
white  soluble  powder  of  definite  chemical  composition) 


CAUSES  AND  RELIEF  OF  DENTAL  PAIN.        13 

and  injections  containing  encaine  combined  with  adrenalin 
frequently  do  very  well.  Novocaine  can  be  obtained 
either  in  the  form  of  tablets  to  be  dissolved  in  sterilised 
water  so  as  to  make  a  1  to  2  per  cent,  solution,  or  as  a 
2  per  cent,  solution  ready  prepared  for  dental  use ;  it  is 
of  the  utmost  importance  that  whatever  solution  is  used 
must  be  freshly  prepared  and  sterile. 

For  difficult  extractions  the  2  per  cent,  solution  should 
be  used ;  for  simple  extractions  the  1  per  cent,  solution 
is  sufficient. 

A  very  satisfactory  syringe  is  that  designed  by  Dr. 
Dawson,  of  Dublin,  as  it  is  readily  sterilisable,  and  more- 

FlG.  1. 


over,  l)y  reason  of  its  "  finger-rings,"  affords  a  perfect 
command  over  the  barrel  and  piston. 

Procedure.  —  (1)  The  patient's  mouth  should  be 
thoroughly  rinsed  with  sanitas  and  water  or  a  perman- 
ganate of  potash  mouth-wash. 

(2)  A  swab  of  cotton- wool  soaked  in  U)  per  cent. 
novocaine  or  cocaine  (10  per  cent.)  solution  is  held  by 
the  patient  over  the  part  to  be  injected,  so  as  to  anfes- 
thetise  the  mucous  membrane  to  the  prick  of  the  needle. 

(8)  The  syringe  is  next  warmed  and  sterilised,  and  the 
needle  should  be  boiled  in  a  small  test-tube  before  use. 

(4)  If  novocaine  is  used  the  syringe  should  then  be  filled 
with  17  minims  (1  c.c.)  of  the  1  or  2  per  cent,  solution 
according  to  the  difficulty  of  tlie  extraction,  and  then  an 


l-i         CAUSES  AND  RELIEF  OF  DENTAL  PAIN. 

injection  made  of  about  12  minims  on  the  external  and 
4  jninims  on  tlie  internal  side  of  the  alveolus,  the  aim  of 
the  operator  being  to  surround  the  tooth  with  a  zone  of 
anaesthesia,  and  for  this  purpose  at  least  two  punctures 
are  necessary;  the  point  of  the  syringe  should  be 
inserted  about  3  mm.  from  the  free  edge  of  the  gum 
adjacent  to  the  tooth  to  be  removed ;  the  needle  should 
be  inserted  quickly  and  the  injection  made  very  slowly, 
the  syringe  being  held  in  position  for  some  seconds  after 
the  requisite  quantity  has  been  injected.  When  the  gum 
becomes  blanched,  and  not  till  then,  the  anaesthesia  may 
be  regarded  as  complete. 

Hypodermic  Injection  of  Adrenalin  and  Eucaine. 

^  Beta-eucaine      .         .         .         .         §^-  -k 

Adrenalin  chloride     .         .         .         gr.  yoVo 
Aq.  ad.       .....         "^ixvij. 

To  be  freslily  prepared  or  used  from  an  "  ampoule." 

Hypodermic  injections  into  the  gums  should  not  be 
made — 

(1)  In  inflammatory  or  suppurative  conditions  of  the 
mouth. 

(2)  In  cases  of  alveolar  abscess.  In  such  cases  the 
application  of  cotton-wool  soaked  in  10  per  cent,  novo- 
caine  for  some  five  minutes  will  much  alleviate  the  pain 
of  a  dental  extraction. 

The  local  anaesthesia  that  can  be  produced  by  freezing 
the  gums  with  a  spray  of  ethyl  chloride  is  frequently  very 
useful  in  the  case  of  readily  accessible  single-rooted  teeth, 
but  it  must  be  borne  in  mind  that  it  has  a  great  tendency 
to  cause  the  teeth  to  become  brittle  owing  apparently  to 
the  freezing  of  their  "  organic"  matter,  with  the  result 
that  they  may  be  very  readily  broken  during  the  attempt 
at  extraction  and  thus  lead  to  much  difiicultv. 


GENERAL  NOTES  ON  EXTRACTION  OF  TEETH.     15 


GENERAL    NOTES    ON    EXTRACTION    OF 

TEETH. 

The  minimum  number  of  forceps  that  can  he  expected 
to  deal  with  an)^  ordinary  case  of  extraction  is  five,  and 
this  num])er  combined  with  a  "  fish-tail"  elevator  will  be 
sufficient  for  practically  every  tooth.  In  Figs.  2  and  3 
the  patterns  suggested  are  shown  together  with  a  pair 
of  "  conveying  forceps  "  such  as  are  very  useful  for  apply- 
ing medicaments  on  cotton-wool  for  the  relief  of  pain, 
and  also  a  dental  probe  for  ascertaining  the  exact  position 
and  extent  of  carious  cavities. 

The  use  of  so-called  "  straight"  forceps  for  lower  molar 
and  bicuspid  teeth  is  not  recommended,  as  they  are 
exceedingly  difficult  to  use  and  do  not  provide  nearly  as 
much  leverage  as  those  of  the  so-called  "hawksbill" 
pattern  as  shown  here.  The  blades  of  all  dental  forceps 
must  be  bevelled  so  that  they  grasp  the  teeth  on  a  flat  and 
not  a  sharp  edge,  as  is  frequently  the  case  with  ill- 
designed  forceps,  which  simply  break  the  teeth  instead  of 
grasping  them. 

The  "  straight "  elevator  is  not  recommended,  as  not 
only  is  it  difficult  to  use  but  is  an  exceedingly  dangerous 
instrument  in  the  hands  of  one  unaccustomed  to  its  use. 

It  is  of  the  utmost  importance  that  all  instruments 
used  for  extracting  teeth  should  be  efficiently  sterilised, 
either  by  boiling  or  else  by  prolonged  soaking  in  a  solu- 
tion of  carbolic  acid  (1  in  20)  or  biniodide  of  mercury 
(1  in  8000) ;  it  is  also  essential  that  the  forceps  should 
be  clean  in  the  ordinary  sense  of  the  word  before  being 
placed  in  the  antiseptic  lotion. 

Inasmuch  as  few  practitioners  possess  the  luxury  of  a 
dental  operating  chair,  a  convenient  substitute  can  be 


16  GENERAL  NOTES  ON  EXTRACTION  OF  TEETH. 


GENERAL  NOTES  ON  EXTRACTION  OF  TEETH.     17 


18  GENERAL  NOTES  ON  EXTRACTION  OF  TEETH. 

readily  devised  as  shown  in  Fig.  4  by  placing  two  strong 
chairs  back  to  back  against  a  wall  in  snch  a  way  as  to 
prevent  the  chair  in  front  from  being  tilted  backwards  by 
the  flinching  of  the  patient  or  the  efforts  of  the  operator. 
This  plan,  combined  with   such  other  positions  as  are 


A.  Cushion  on  back  of  cLairs.     b.  Chair  resting  firmly  against  a  wall. 

shown  in  dealing  with  particular  teeth,  is  suflicient  for 
every  case. 

Special  care  must  be  taken  when  extracting  a  tooth 
that  stands  alone ;  it  frequently  happens  that  the  gum 
is  firmly  adherent  to  a  tooth  of  this  kind  and  may  there- 
fore be  seriously  torn  during  the  process  of  extraction ; 
in  such  a  case  it  may  be  necessary  to  cut  away  the  tag 
of  gum  with  a  lancet  or  scissors. 


THE  EXTRACTION  OF  TEMPORARY  TEETH.       19 

THE    EXTRACTION    OF    TEMPORARY 
TEETH. 

All  the  temporary  teeth  exce})t  the  molars  have  one 
root. 

There  are  no  bicuspids  in  the  temporaiy  dentition. 

The  position  of  the  temporary  molars  is  occupied  by 
the  bicuspids  in  the  permanent  dentition. 

The  hicuspids  erupt  between  the  roots  of  the  "  tem- 
porary molars,"  and  therefore  occupy  their  position 
when  they  are  lost. 

In  extracting  the  temporary  teetJi  tli.e  ixtticnt  should  he 

Fig.  5. 


The  teniporaiy  teetli. 

jjlaced  in  the  same  jjosition  as  for  the  corresponding  j)er- 
manent  teeth. 

General  principles. — Grasp  the  crown  of  the  tooth 
firmly  in  the  forceps. 

In  the  case  of  a  temporary  molar  it  is  important  to 
avoid  pressing  the  forceps  upwards  or  downwards  to  any 
appreciable  extent  for  fear  of  removing  the  crown  of  an 
on-coming  bicuspid  which  lies  between  its  roots  ready 
to  take  its  place. 

For  niqjer  incisors  or  rarrlnes  use  "straight"  or  bayonet 
root  forceps. 

For  upper  molars  use  right  or  left  up})er  molar  force])S 
or  bayonet  root  forceps  in  cases  where  the  crown  is 
much  broken  down. 


20       THE  EXTRACTION  OF  TEMPORARY  TEETH. 

For  lower  incisors  or  canines  use  lower  hawksbill 
root  forceps;  the  same  forceps  can  be  used  on  either  side 
of  the  mouth. 

For  loujer  temjjorarij  molars  use  lower  hawksbill 
molar  forceps  or  lower  hawksbill  root  forceps. 

Broken-down  temporary  teeth  and  roots  can  either  be 
extracted  with  root  forceps  or  prised  out  with  the  "  fish 
tail "  elevator,  making  use  of  an  adjacent  tooth  as  a 
fulcrum. 

It  is  quite  unnecessary  to  have  special  forceps  for 
temporary  teeth. 

It  is  important  to  avoid  extracting  prematurely  a 
second  temporary  molar;  loss  of  this  tooth  may  lead  to  a 
moving  forward  of  the  adjacent  first  permanent  molar 
and  consequent  crowding  and  irregularity  of  the  bicuspid 
teeth. 

The  temporary  canines  should  also  be  retained  until 
their  permanent  successors  show  signs  of  erupting; 
premature  extraction  of  the  temporary  canines  allows 
the  bicuspid  teeth  to  move  forward  and  thus  may  lead 
to  the  deformity  of  projecting  canine  teeth. 

Undue  retention  of  the  temporary  teeth  may,  on  the 
other  hand,  lead  to  irregularity  of  the  permanent 
successors ;  in  cases  of  doubt  it  may  be  well  to  postpone 
extraction  until  the  advice  of  a  dental  surgeon  can  be 
obtained. 


Dentition  Table. 

The  following  table  shows  the  order  in  which  the  milk 
teeth  and  permanent  teeth  appear,  and  the  average  age 
at  their  eruption.  There  are  wide  variations  as  to  time, 
and  great  irregularity  in  the  order  of  their  appearance. 

MilJc  teeth. — The  first  dentition  begins  at  the  sixth  or 


HEMORRHAGE  AFTER  EXTRACTION. 


21 


seveiitli   niontlij   and  is  completed  by  about  the  second 
year. 

(1)  lower,  6tli  month;   (2)  npper, 

7tli  month. 
(1)  upper,  9th  month;   (2)  lower, 

10th  month. 
12th  month. 
18th  month. 
2nd  year  (often  later). 
The   full  primary  dentition  is   20  teeth;    10  in   each 
jaw. 

Permanent  f('(4]i  .- 


Central  incisors 

Lateral  incisors 

First  molars 
Canines 
Second  molars 


First  molars    . 

6. 

\  years 

Lower  central  incisors 

7 

L'pper  central  incisors 

8 

Lateral  incisors 

9 

First  bicuspid 

10 

Second  bicuspid 

11 

Canines  . 

12 

Second  molars 

1:', 

Third  molars  (wisdom)    . 

17 

to  25  years, 

or  at  any  later  period 

The  full  permanent  dentit 

ion  is  3 

2  teeth ;  1 6  in  each  jaw 

H/CMORRHAQE    AFTER    EXTRACTION: 
TREATMENT. 

Local. — In  slight  cases  it  is  sufficient  for  the  patient  to 
sit  quiet  with  cold  or  iced  water  in  his  mouth;  where  ice 
cannot  he  ol^tained  holding  very  hot  water  in  the  same  way 
is  often  successful,  especially  if  alum  be  dissolved  therein. 

It  is  not  infrequent,  however,  that  l)lood  will  continue 
to  well    11])   fTT)ni  the  socket   fi'oni   Avliich  the  tooth  has 


22  HTEMORRHAaE  AFTER  EXTRACTION. 

been  removed;  in  such  a  case  it  is  necessary  to  syringe 
the  socket  with  ice-cold  or  very  hot  water  or  boric  lotion 
and  then  to  apply  pressure  to  the  bleeding  point  by  firmly 
plugging  the  socket  with  cotton-wool  or  lint  soaked  in 
fresh  adrenalin  or  other  supra-renal  gland  preparation ; 
the  application  of  tannin,  either  as  glycerine  of  tannin  or 
on  wool  soaked  in  hazeline  and  powdered  with  tannin, 
answers  in  many  cases.  Perchloride  of  iron  is  a  most 
unsatisfactory  remedy,  and  should  only  be  used  as  a  last 
resource  when  nothing  else  is  obtainable. 

Constitutional . — It  is  not  uncommon  for  an  operator  to 
be  warned  by  the  23atient  that  excessive  bleeding  has  pre- 
viously followed  the  infliction  of  a  cut  or  the  extraction 
of  a  tooth.  It  has  been  shown  that  a  large  proportion  of 
these  cases  are  due  to  insufficient  coagulability  of  the  blood 
owing  to  an  insufficiency  of  calcium  salts ;  it  is  therefore 
wise  in  such  cases  to  administer  one  of  the  drugs  which  are 
known  to  rapidly  increase  the  coagulability  of  the  blood. 

Calcium  lactate,  calcium  chloride,  and  magnesium 
carbonate  have  all  been  shown  to  produce  this  effect  in 
a  marked  degree  within  the  space  of  an  hour  or  so ;  the 
salt  selected  should  be  administered  in  a  single  dose  of 
5J  the  night  before  the  proposed  operation. 

The  best  and  most  pleasant  to  take  is  calcium  lactate, 
which  may  be  administered  in  compressed  tablets  or  in  a 
draught  such  as  the  following  : 

1^  Calcii  lactatis      .         .         .         .         .         .         5j. 

Syrup  .......         q.s. 

Aq.  ad.         .......         ^j. 

Fiat  haustus. — Tu  be   taken   as   a  draught  the   night  before   the 
dental  extraction  takes  place. 

The  effect  of  these  salts  appears  to  last  about  three 

to  four  days,  so  that  in  the  event  of  dental  extractions 

being  performed  on  successive  days  a  second  dose  is  not 

called  for. 


PAIN    AFTER    EXTRACTION.  28 

PAIN    AFTER    EXTRACTION. 

Pain  after  the  extraction  of  a  tooth  may  be  due  to  the 
lateral  displacement  of  the  alveolus  which  is  brought 
about  by  the  application  of  the  forceps ;  this  can  be 
minimised  by  applying  firmly  a  finger  and  thumb  after 
the  tooth  has  been  removed  and  so  restoring  the  alveolus 
to  its  former  position. 

Besides  this,  owing  to  the  socket  becoming  septic 
either  from  the  operator  making  use  of  unsterilised 
instruments  or  else  operating  in  a  mouth  that  is  very 
foul,  pain  may  continue  in  a  tooth  socket  for  a  consider- 
able time. 

To  avoid  this  every  mouth,  before  operation,  should  be 
made  as  clean  as  possible  by  the  use  of  tooth-powder  and 
sanitas  and  permanganate  of  potassium  mouth- washes,  and 
after  the  extraction  has  taken  place  every  effort  must  be 
made  to  keep  the  socket  free  from  the  remains  of  food 
and  other  decomposable  matter.  If,  two  or  three  days 
after  the  extraction,  the  patient  complains  of  pain  in  the 
socket,  the  treatment  is  to  keep  it  syringed  out  with 
sanitas  and  water. 

A  pledget  of  cotton-wool  soaked  in  liquor  potassse  and 
pure  carbolic  acid,  equal  parts,  usually  affords  immediate 
relief  from  pain  after  the  socket  has  been  syringed  out 
in  this  way. 


INDEX. 


Aconite  and  iodine  paint.  4 
Acute  inflammation  of  pulp,  4 
Adrenalin  and  beta-eucaine  injection. 

14 
Alveolar  abscess,  10 
Ansestliesia,  local.  12 
Anodyne  applications.  3 
Arsenic  for  dental  pnlp.  6 

Beta-eiicaine,  14 

Bicuspids,   extraction   of   right    and 
left  nppei",  plate  3 

—  —  of  I'ight  lower,  plate  4 

of  left  lower,  plate  5 

Biniodide  of  mercury,  li") 

Calcium  chloride,  22 

—  lactate,  22 

Canines,  extraction  of  upper,  plate  1 
of  lower,  plate  2 

—  temporary,  preuiature   extraction 
of,  20 

Carbolic  acid.  3.  '> 

Carbolised  resin.  3 

Carbonate  of  magnesium,  22 

Chaii-.  operating,  18 

Chloride  of  ethyl,  14 

Chronic  dental  periostitis,  7 

ChroTiic  suppurative  inflammiition  of 

pulp,  (> 
Collodi<m,  flexilde,  11 


Dental  periostitis,  7 
Dentition  table,  20 
Destruction  of  dental  pulp  l)y  arsenic. 
6 

Earache.  5 

Elevator,  use    of,  jjlates  10,  11,  and 

page  15 
Eruption  of  teeth,  order  of,  21 
Ethyl  chloride,  14 
Eucaine.  14 
Extraction,  haemorrhage  after,  21 

—  pain  aftei",  23 

—  of  temporary  teeth.  19,  20 

—  of    permanent    teeth    (aee    mider 
vames  of  teeth). 

Fig-poultice,  11 
•'  Fish-tail"  elevator,  plate  10 
Fomentations,  poppy-head,  11 
Forcej^s,  IH,  17 

Gag,  Mas(  m"s,  11 
Gingivitis,  10 
Glands,  infection  of,  1 1 
Gum-boil.  10 

Ht«mophiliii,  21 

Ha!moiThage  after  extraction,  21 

Hawksl)ill  forceps,  IT) 

Improvised  operating  chair,  18 
Incisors,  extraction  of  upper,  phite   1 


26 


INDEX. 


Incisors,  extraction  of  lower,  plate  2 
Inflammation  of  the  pulp,  1,  4 
Inflammation  of  dental  periosteum,  2 
Instruments,  sterilisation  of,  15 
Iodine  and  aconite  paint,  4 

Lactate  of  calcium  in  lisemopliilia,  22 
Local  ansesthesia,  12 

Mason's  gag,  11 

Masseter,  spasm  of,  11 

Merciirial  poisoning,  7 

Mercury,  biniodide  of,  15 

Molars,   extraction   of    right    tipper, 

plate  6 
of  left  itpper,  plate  7 

—  —  of  right  lower,  plate  8 
of  left  lower,  plate  9 

—  prematui'e     extraction     of     tem- 
porary, 20 

Novocaine,  12 

Operating  chair,  18 

Pain  after  extraction,  23 

—  referred,  5 
Perchloride  of  iron,  22 
Periostitis,  dental,  7 
Phosphorus  poisoning,  7 
Polypus  of  loulp,  7 


Poppy-head  fomentations,  11 
Potassium  chlorate,  9 
Ptyalism,  9 

Pulp,  inflammation  of,  4 
Pyorrhcea  alveolaris,  8 

Referred  pain,  5 

Resin,  carbolised,  3 

Riggs'  disease,  8 

Roots,  extraction  of,  plates  10,  11 

Scarring  of  face,  11 
"  Straight  "  forceps,  15  and  plate  1 
Stumps,  extraction  of,  plates  10,  11 
Suppurative  inflammation  of  dental 

pulp,  6 
Syringe,  Dawson's,  13 

Tannin  in  haemorrhage,  22 
Teeth,  order  of  eruption  of,  21 
— ■  permanent,  plates  1-11 

—  temporary,  19 

Temporary  teeth,  extraction  of,  19 

—  premature  extraction  of,  20 

—  shapes,  19 
Trismus,  11 

Wisdom   teeth,  extraction   of  lower, 

plate  10 
of  upper,  plates  6,  7 


PLATE    ]. 

Extraction  of  Uppee  Ixcisoks  and  Canines. 


CM 


I— 1 

12; 
O 

ft 


pi 

p^ 
P 
o 

o 

o 

<l 

w 

en 

1X1 


Ph  O 
cS    O 

'^  .2 


2  p^ 


cq 


I-  a  ^ 

r  lij  ^ 

y  &•  z 


*-5^r^ 


(33 

2  3 


5     OJ 


^  -tJ  -(J 


T"    "5  a> 


2^ 


•^    "O    r^ 


'^  Or; 

i-S| 

T-                 CS          • 

S  =1-1     O  rrt 

^^ 

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<"    r^      -        '^ 

C/) 

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a 

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4> 

u 

a>  a   •" 
a)    m    OJ 

,-/j    CD    o    rt  . 

o    cc    r;    t-i 

2  ^      rH    cG 

03  r— (      ^         O 

SS  o 

c 
o 

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a 
< 


b^ 
■^  ^ 


P'5 

O 


^-5 


=c    g 


0  ?5 

^§ 

01  ^ 

(V    o 
!=1  -S 


PLATE    2. 

EXTEAC'Tinx    OF    LoWER    CaXIXES,    ALL    LoWER    TnCISORS, 

AND  Incisor  and  Canine  Roots. 


p^ 


O 


o 

•v 

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1— 1 

o 

o 

1^ 

rH 

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r^ 

C/J 

Tr 

W 

'm 

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OJ 

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CO 

H 

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dJ 

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t— 1 

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EH 

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03 

3 
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f 
o 

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02 

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h-1 

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1— 1 

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k<; 

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a-  ^    «i 

a  *  n 


^y  S  D 

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rJH 

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cS 

tt 

m"--^  U  *  Z 

S 
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f^'^.-* 

o 

(N3d0) 

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it'  -, 


a> 

ci  03       y 

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o 

•5    cc!  -(--  cpl 

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tS 

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c3 

^_    CO    p: 

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r^ 

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m 

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m    „    ;h   <u 

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i-^   •—'              Ph 

oJ  •r'    <w 

in 

Q. 

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^ 

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r— 

o 

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c 

-^^P^-^* 

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'IfJ 

CO 

CJ 

;i 

a 

5 

a 

CO 

< 

PLATE   3. 

EXTKACTION    OF    RlGHT    AND    LeFT   UpPEE    BiCUSPlDS. 


« 
I— ( 

Ph 

o 

pq 


<5 


O 

o 

I— I 

o 

p^ 


2  ^ 

be  i^  rt 

a  p  ^ 

O  &H  ^ 

;h  aj    a 

|h  0/  ce 

aj  i»  -*- 

5i  "d  r' 

^  t^    tD 

O  ta    S 

-*J  -k^  ^ 


a> 


<v 


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r^  2^  o  8 

O    !=1    o    S 


=;   Qj   d    2   rt  _2 


o   J£ 
11 


^  :3  r-  trj 


CD      &H   S 


1) 


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U 

o 
U. 


c 

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y 

"5. 
& 
< 


J  'g  '^  o  •- 
3  o  S  ^  5s 


d  -^ 
S  ^ 


PLATE    4. 

Extraction  of  Right  Lower  Bicuspids  and  Lower 
Roots  on  the  Right  Side  of  the  Mouth. 


Ed 
W 

o 
o 


I— I 
P^ 


w 

O 

CQ 

o 
o 

p^ 

O 
<i 


(N3d0) 

3ZIS  mnj 


P 

o 

pq 

K 
C 

PC 

o 

12 
o 

■-H 

O 
(^ 
X 

pa 


•rt  ^  ^^  s  '^ 


cuspi 
ough 
een  tl 
undii 

-t^ 

=t-i 

o 

rig 
;e  of 
des 
the 

m 
03 

S  S^^ 

^ 

low 
orta; 
\e  b 
1  an 

be 

c3    ft-P  ^3 

O^ 

S        o 

•r-i 

Idin: 
the 
dow 
he  i 

u   tn 

aj   CO 

S    ft 

OJ    o    0)    o 

3  ~o 

O    rt    ^    QJ 

:=!^  ftfl 

bC-S 

^ 

■rH      O 

a< 

O  -4-^      " 

Z.    cS'JH 

^ 

=  fM  ° 

Vf^ 

-j            CO 

Vi        a- 

a; 

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^  c;  ^ 

ci 

&C   P      rH 

m 

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2 

^  S  oi 

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d 

Q   S  T 

CO 

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(-^  "T^ 

S|^^ 

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o 

6j:  p: 

+a 

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tn 

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cS 

g  ce 

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CO      ^ 

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tn 

1. 

If 

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*  >. 

■r,      ^ 

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rt 

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ce 

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ci 

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1 — 1    a3 

0)    ^ 

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s  g 

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d 

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a 

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a 

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^ 

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ei 

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Q) 

Oh 

O 

PLATE    5. 

ExTKACTiox  OF  Left  Lowek  Inoisoes,  Bicuspids,  and 
ALL  Roots  on  Left  Side  or  Mouth. 


w 


p 

o 

^ 

pq 

o 

^ 

p 

03 

'S 

J^ 

'& 

m 

^ 

o 

^ 

h^ 

^ 

>^ 


0 

rj 

0 

c3 

P5 

CO 

ij 

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05 

16 

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u 

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pi! 

in 

0 

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f^ 

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m 

f=^ 

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0 

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0 

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0 

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ps 

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r— '      ^ 

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D 

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2.S    --^ 

L, 

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rf    iC  CO 

.  i       „      32 

r-    1 1       72       r^ 

•-*-'     32    -^j     — ' 

o  ^^        o 

o  ':n  s  <i^ 

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O    -^^   ^M 

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a 

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2 

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ci 

' — ''   C3   r^      32 

o  S 

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^   r2      ^      !=| 

»  "^ 

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A--^'           '^ 

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a 

bcj 

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o 

3,  ,x   2i   a. 

^     .'/) 

c 

_o 

:^    -^ 

'•5 

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CQ 

^  ."t^ 

u 

a 
< 

PLATE    G. 

Extraction  of  Right  Upper  Molars. 


^<-^. 


Oh 


o 


o 

I— I 

EH 

O 


"apuxci  '^s^^^O 


•epuxq.  JS^iiQ 


<^  ®  15  "o  &» 
IB  oj  n  o  CS 

g^  §  s  ^ 

-t^  J  ce  o)  o 

■g  -^  bD  S   >,  g 

CD  ,5  *  ^  2  -p 
S  c  2  ~S  ^  '^ 


^*-t  =4-1  a;    I    o 

O    O    S    CO  4j 

>4  rt  S  o 


V3   ■ 

be 


5;  -e  .2 


bC^     0   4- 


« 


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^ 

ca 

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fii 

y 

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ri 

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ci  ^ 


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oa 


&H 


r3 


T3    ,• 

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^  r3 

IS     R     o 

g  c3  ai 

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d    -4^   I— 1 
53     (u     cj 


qn    y 


5    =*    cc 


P^ 


u 
o 

u. 


7  .EP  S  .o 


C 
_o 
'•5 

a 
a 
< 


PLATE    7. 
Extraction  of  Left  Upper  Molars. 


'^» 


O 

a 

o 

(U 

i^ 

Oi 

ZJ 

l- 

'-+3 

.^ 

ts 

X 

"le 

Ph 

c5 

?> 

^ 

'ts 


r^   o  -^  :o  -iaii 


oj   b€"^ 


'S  ■"■  15  o  ''  i^ 


-S  bc^  o 


,  .     g   o  *  •-- 
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«  §  §  s  ^ 


o  o 


o^  o  S  « 

IK  II 
Pi 


o  o 


Ph.S       ^.2 

5+-I     p  rp-^     (^ 

2  S       =^  '^  ,S 


a 

(U 

u 
o 


I— i'   03     C)  -^^ 

--2       ^    -M  O 

"o'm    ^  2 

-M    (V,    O    O    S  !^ 

2   =*H    -M   r^  Ol 


Oh 


o  <1      P^ 

c 
o 


o 

"a 

a 


PLATE   8. 
Extraction  of  Right  Lower  Molars. 


00 


o 

E- 

p2 


o 

p= 


>> 

s 

% 

ft 

c3 

-s 

^ 

nS 

-P 

O 

,r3 

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be 

-p 

'fH 

a> 

f-t 

s 

cS 

be 

O 

fl 

-P 

■? 

o 

r^ 

02 

■  \ 

Wi-^iii 

AttBHi 

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nuif  ' 

jwAirt^ 

V 

* 

:ii 

1^^ 

^ 

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=^      .5 


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-f^ 

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o 

!^,0 

_c3 

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^    ^ 

^ 

1^. 

c3 

r^ 

a>  =i 

rf 

^   g^ 

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!>^S 

.9 

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a    S3 

rt   ^. 

p 

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p , 

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o 

S    ^ 

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p 

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p 

r;  _g 

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ri       ^* 

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P       © 

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be 
o 

2       % 

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03 

03 

2 

o , 

1:5  =^ 

3 

o 

11 

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d    -"^ 

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o 

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2 
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tfl 
a 
a> 
u 

II 

Ci_i       ^ 

0) 

03 

o 
o 

P- 

O 

1  S  t^-i 

Si 

;_,      03 

e  same  time, 
il"  elevator 
se  of  "  fisli-t 

o 

<^ '   rj} 

Pi 

;_, 

O-    ri^ 

^    c«    P 

U. 

<*- 

o 

tH 
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c 

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^  ^  = 

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^o 

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0)            P 

(J 

^ 

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«<-( 

•?3   c 

< 

PLATE   9. 

Ex'i'h'ACTiON  OF  Left  Loavek  Molaes. 


C5 


o 


o 
o 


fe 


3  Ti 

?    c3 


■t;  '-c  -= 


S  2 

.9 

S=  ^ 

-2  -*^ 

^ 

cu 

"^ 

_2 

r=^    '^ 

-t-i    OJ 

i-i 

■^^ 

o 

-^3 

•+^  s 

a 

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o 

03 

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M 

t;  ^- 

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+^ 

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o   " 

o 

cc 

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-2 

2 

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2 

%  ? 

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ia 

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as     r1 

e4H 
O 

-yj 

a;    O 

•^i 

S  -^ 

•Jl 

S 

>,^ 

;3 

^ 

^  "S 

tp 

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2  1 

^ 

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r^ 

S 

5-4       ^ 

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C|H    'VH 

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5°      >% 

■jf 

ni? 

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O 

'-'          > 

g.s 

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S 

s^ 

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o 

^5' 

'o 

cc 

T— 1 

i-H 

3  -'"- 

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J5 

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o 

■A 

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c3 

o  qs 
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_, 

5  ^  t^ 

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O 

^ 

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r^  'o    ^ 

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^  2 

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2-^  i 

o 

^ 

13  ^^ 

-t-i 

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^ 

2    SE 

' — •  ri 

o 
o 

2 

O    :3    O 
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•n 

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o 
3 

3 

>     5-< 

r^ 

t^      rH    -tJ 

o 

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^-^    >■ 

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'^ 

^    S 

'% 

X-    j^  ^ 

-Jl 

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0) 
•yj 

O 

.2  ^  «j 

•jA 

ceps : 

forceps 
ovcibly 

o 

3 

r2 

=4-1 

o 

•A 

h      "      <4-( 

3^  s  ^ 

, 1 

(U 

"o   <j  (£i  ^  <ti    :3  :: 


c 

"a 
< 


3  2  pi 
f  H  =S 


PLATE    10. 

EXTRAC'TIOX   OF   UpPETJ    AND    LoWKE    RoOTS   AND   LoWER 

Wisdom  Teeth. 


2\     ^     m     ^  ?Hp:3?-iCDco             ©CD  tc5p4J 

.t^    -^    ^    ^  c^     5     O    ^    •"           ^     o  •"      B    ^ 

^         "i^i^a^p.^  .'^^<X)OmU  goo 

O)             i-i       ?n       rr!  ^^              -O      "+-^       O       O  rH       i^ 

•"          5"            >ir^  <-i*^-|'^-i?H,.^CD_^;H  J3^" 


5  ^  Ph.T^;h^3  M^?^Oq3ofl_  ©^ 


•+3 


t<     |«rg-^-^|^i^§po:^^| 

1^^  J"  ^1^^^^  f^=«  o^t 

o,^  o  a^r^o-r^co  H«+-i  ^  :=s 


p 


PLATE    11. 

The  Use  of  the  Elevator  foe  Extracting  Lower 
Stumps  and  Lower  Wisdom  Teeth. 


<! 


Eh 

o 
p 


o 

o 

w. 

Ph 

0^ 
O 

a 
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o 
o 

\A 

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pR 
o 

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EH 


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bp.S 
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Atlas  of  dental  extractions. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.slx) 

RK531W15C.1 

An  atlas  '.y  "..,,:..„.■„.,;;;,„;„ 


2002399334 


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